Herniation of urinary bladder is a relatively uncommon but not a rare condition. It occurs when the urinary bladder or ureter herniates into the inguinal canal, scrotal sac or femoral canal. Herniations through ischiorectal, obturator or abdominal wall openings have also been described. Bladder herniation into the scrotum has also been called "scrotal cystocele".
It is important to be aware of this condition in any males older than 50 years with inguinal hernia, as unknowingly, bladder injury during herniorrhaphy can lead to infection, sepsis or even death.
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Herniation of bladder is seen in 1-3% of inguinal hernias. It is seen in 10% of men older than 50 years. Femoral hernias are more common in women. These hernias have a predilection for right side1 .
Most are asymptomatic, and discovered incidentally during radiological evaluation of inguinal hernias. However, symptoms such as dysuria, frequency, urgency, nocturia and hematuria are also common. A typical symptom, will be reduction of hernia size after passing urine, and the ability to pass urine after pressing the hernia sac 1.
Many factors can lead to bladder herniation:
- chronic bladder distension (e.g. prostatism) and its contact with inguinal canal
- loss of bladder tone
- perivesical fat protrusion
- space-occupying pelvic mass lesions
- Paraperitoneal hernia: most frequent type, in which extraperitoneal portion of hernia lies along medial wall of sac.
- Intraperitoneal hernia: herniated bladder is thus completely covered by peritoneum.
- Extraperitoneal hernia: bladder is not covered by peritoneum at all.
However, anatomical classification of inguinal hernias (direct and indirect) can also be applied.
A wide-mouthed rounded protrusion of bladder wall directed downwards is seen.
Indirect signs are:
- small asymmetric bladder
- incomplete visualization of bladder base
- lateral displacement of lower ureter
One important technical consideration is positioning of patient - In typical supine radiographs, they are usually missed. Prone position can improve the detection, while erect radiographs can detect 100% of such hernias.
It is the best technique to image bladder hernia. However, bladder herniation is still visible during voiding.
Pointing of bladder towards the side of hernia, i.e. angulation of bladder base anteroinferiorly, is the CT sign of bladder herniation. Prone position can enhance its visualization. CT can also reveal herniations through uncommon sites like the obturator foramen.
Usually only large scrotal lesions can be well visualized in sonography. Fluid filled sac in continuity with urinary bladder is seen. Sometimes, this continuity is difficult to demonstrate, where it is seen as beaked appearance of fluid filled scrotal sac cranially 1.
Findings are similar to CT features of bladder hernia, however coronal and sagittal planes can clarify the issue. Also, relations to adjacent vascular landmarks can be well identified 1.
General imaging differential considerations include
- bladder ears: in young infants, normal protrusion of lateral aspect of bladder is seen into the inguinal canal, called "bladder ears"
- cystocele: are usually triangular and along the midline, whereas bladder hernias are projected laterally
- urinary bladder diverticulum 3
- ureteral hernia
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